Child and Adolescent Mental Health

1. Child and Adolescent Mental Health

2. Cognitive Development • Moves from concrete thinking to “formal operations” -Abstract thinking • Level of thinking allows the person to transfer information from one situation to another, deal efficiently with complex problems, and plan realistically for the future. • Physical development precedes cognitive development • The last part of the brain to mature is the prefrontal cortex • Adolescence is a time of profound change in brain function.

3. Mental Health Problems of School Age Children • 10-13% of children have serious MH problems • 655,000 Texas children

4. Etiology of MH Problems • Genetics: strong for Depression, Anxiety, OCD, Tic disorders, ADHD, Bipolar • Environment: • Abuse and neglect, (actually causes a change in structure of the brain) • Intrauterine: Fetal Alcohol Syndrome • Other: Poverty, Lead poisoning, Brain injury, etc.

5. Etiology, cont’d • Neurological Anomalies • Developmental disorders- MR-IQ below 70 , Axis II • Pervasive developmental disorders-Autism, Asperger’s, PDD-NOS, Etc.

6. Main Content • Developmental Disorders • Attention Deficit and Disruptive Behavior Disorders • Pervasive Developmental Disorders • TIC Disorders • Psychotic and Mood Disorders • Elimination Disorders • Psychopharmacology • Cognitive Behavioral Therapy

7. Developmental Disorders • Mental Retardation • IQ< 70 • Pervasive Developmental Disorders • Autistic Disorder • Asperger’s Disorder • Pervasive Developmental Disorder NOS • Specific Developmental Disorders • Learning Disorder • Communication Disorders • Speech and language disorders are strongly associated with psychiatric disorders

8. Attention Deficit Hyperactivity Disorder (ADHD) • Inattention • Impulsivity • Overactivity • Restless overactive, distractible, reckless, disruptive • Up to 11% of school age children • Psychological adversity

9. Etiology of ADHD: Neurobiology • Frontal Lobe Dysfunction: area of brain responsible for planning, attention, regulation of motor activity • “Underactive brain” • Reduced metabolic activity • Not enough Dopamine • Hypoperfusion

10. Pharmacotherapy for ADHD • Stimulants: methylphenidate (Ritalin), detroamphetamine (Dexedrine), and mixed amphetamine (Adderall) • Extended release--Ritalin LA; Metadate CD and Concerta--decrease dosing to once daily • Adderall XR is also extended release

11. Stimulant Medication Issues • Dose regular stimulants just prior to meals to decrease anorexia • Non-extended release require noon dosing and a smaller dose in the evening to prevent rebound • Side effects: anorexia, weight loss, abnormal movements, labile mood, insomnia, over focused on details, agitation

12. Other Medications for ADHD • clonidine (Catapres) also used: reduce norepinephrine activity in the brain • atomoxetine (Strattera) • Has a different mode of action from amphetamines, not a schedule II drug • Capsule form of 10,18,25,40,60 Mgm • Affects reuptake of Norepinephrine

13. Side Effects of Strattera • Most common: dyspepsia, nausea, vomiting, fatigue, appetite decreased, dizziness, and mood swings • Less common: insomnia, sedation, depression, tremor, itching, dry eyes, sexual dysfunction • Adverse events: Increased heart rate and blood pressure--albuterol inhalers can increase CV effects • Drug interactions: Paxil and Prozac

14. Disruptive Behavior Disorders • Oppositional Defiant Disorder (ODD) • Enduring pattern of disobedience • Argumentative • Explosive (Impulsive) • Frequently in conflict with adults • Tendency to blame others • Comorbid Diagnosis with ADHD, anxiety and mood disorders

15. Disruptive Behavior Disorders, cont’d • Conduct Disorder • More serious violations of social standards • Higher than expected rates of ADHD, depression and learning disorders • Associated with adult Antisocial Personality Disorder dx.

16. Pervasive Developmental Disorders • Impairment across multiple domains (impairment is global) • Psychological Impairment • Social Impairment • Academic Impairment • May meet the standard for Mental retardation

17. Pervasive Developmental Disorders • Autistic Disorder • Asperger’s Disorder • Pervasive Developmental Disorder NOS

18. PDD’s Are now viewed as being on the same spectrum, differentiated by severity of symptoms and impairment

19. Autistic Disorder • Early Age of onset • 30 months of age • Constant delayed development • Social relatedness is profoundly impaired • Aloof and indifferent to others • Prefer inanimate objects to human contact • Stereotypical Behaviors • Rocking and Hand flapping

20. Autistic Disorder, cont’d • Alteration in Communication • Delayed and deviant • Abnormal intonation • Pronoun reversals • Echolalia • Insistence on sameness and preoccupation with peculiar interests • The vaccination controversy

21. Asperger’s Disorder • Less likely to be mentally retarded • Communication handicap is less severe • Concrete interpretation of language • Stilted and abnormal intonation • Higher performing • Social interactions impaired • Impaired reading of social cues • Clumsy • Difficulty with transition • Preoccupation with matters of private interest

22. Pervasive Developmental Disorder NOS • Does not meet criteria for more specific type of PDD • Traits of both Autism and Asperger’s

23. Tic Disorders • Tourette’s Syndrome -Movement disorder defined by the presence of motor and phonic tics: Rare 1 to 2 per thousand • Motor Tics-rapid, jerky movements of eyes, face, neck, and shoulders • Phonic tics: grunting, throat clearing, and repetitive noises • Can be words or obscenities • Treatment: haloperidol (Haldol), clonidine (Catapres)

24. Other Psychiatric Disorders • Childhood Schizophrenia- 2 cases per 100,000 • Compare with Autism • Anxiety Disorders: Separation anx. and OCD • Elimination Disorders-often accompany other disorders or as response to stress • Enuresis –bedwetting and/or incontinence during the day • Encopresis—fecal incontinence, soiling or inappropriate depositing of feces • Fecal impaction may cause or result

25. Other Psychiatric Disorders, cont’d • Bipolar D/O and Schizophrenia—Primarily dx. in adolescence • Depression: risk increases when a parent is depressed. • How are the symptoms of depression in children and adolescents different from the symptoms seen in adults?

26. Depression Symptoms Specific to Younger Populations • In Children • Lack of verbal skills affects expression: may be irritable or resistant • In Adolescents • Blues in boys; aggressive behavior or acting out • Blues in girls; anxiety, eating disorders, and or self-cutting. • 2 symptoms to be concerned about: difficulty concentrating and negative statements about themselves and their place in it; like “I’m stupid”

27. General Nursing Interventions for Children: A Behavioral Focus • Keep it simple, structured, and re-enforce good behavior • “It is unsafe to jump down stairs 2 at a time” • “You walked down the stairs in a safe way” • “It is not OK to grab a toy from another child, you must ask” • Simple step-by-step instructions • Daily routine & short term rewards/re-enforcers

28. Other Interventions • Cognitive-Behavioral Therapy • Useful for long term tx. e.g. for OCD, negative thinking in depression, anxiety • May be used in inpatient settings as part of milieu management • “Reinforcement” concepts (negative/positive) • Points and levels • “Extinguishes” negative thinking • Social Skills Training-e.g. for Asperger’s • Problem Solving Skills- reinterpretation of environment

29. More Nursing Interventions • Teach the family about disorders, symptoms and intervention techniques • Assess family HX Listen; be objective when hearing what family has to say • Identify family strengths and successes • Communicate with teachers, school • Passes to go home prior to discharge

30. Pharmocotherapy • Antidepressants • SSRIs : fluoxetine (Prozac)  sertraline (Zoloft)  fluvoxamine (Luvox)  paroxetine (Paxil) citalopram (Celexa) escitalopram (Lexapro) • None are yet officially FDA approved! Also used for OCD

31. Pharmacotherapy, cont’d • SSRIs, cont’d • Activating effects may precipitate hypomania, mania or suicide • TCAs –have been used for many years but effectiveness not proven

32. Pharmacotherapy, cont’d • Antipsychotic Agents • For aggressive behavior, self-injury, tics, psychotic symptoms • Typicals: Highly correlated with EPSEs • Atypicals: Weight gain problematic; fatty livers

33. Interventions: Psychotherapy • Individual Therapy • Play therapy for children • Group Therapy • Family Therapy

34. Community Resources • Support groups, camps, web resources, and literature